How to choose complete revascularization strategies in ACS patients with multivessel coronary disease ?

 

In a subset of patients with acute coronary syndromes (ACS) with multivessel disease (MVD), choose immediate complete revascularization or elective revascularization？ At this conference, a study by Professor Roberto Diletti and his team at Erasmus University Medical Centre Rotterdam in the Netherlands explored this question and presented the latest results.

Professor Roberto Diletti: A large proportion of patients with acute coronary syndrome are also presenting with multivessel disease. There are multiple studies suggesting that complete revascularization is the best way to treat these patients. However, the optimal timing for treatment of non-culprit lesions was still unknown. The aim of the BIOVASC trial was to investigate whether immediate complete revascularization during the index procedure is non-inferior to a staged complete revascularization with a staged procedure performed within six weeks of the index procedure in terms of the primary outcome, which is a composite of all-cause mortality, unplanned ischemia-driven revascularization, myocardial infarction and cerebrovascular events.

What we found is that at one-year follow-up, immediate complete revascularization was non-inferior to a staged complete revascularization in terms of the composite primary endpoint. Other interesting findings were that we found that immediate complete revascularization was reducing overall myocardial infarction incidence. The myocardial infarction rate using immediate complete revascularization strategy was lower compared with a staged complete revascularization strategy. Also, the amount of unplanned ischemia-driven revascularization was reduced with immediate complete revascularization approach.

An important feature of this study is the fact that 44% of all the myocardial infarction in the staged group were occurring in the time window between the index and staged procedure. So there were early events, and those MIs were not procedure-related MIs. There were a total of fifteen cases, and out of those fifteen cases, eleven were type 1 MIs, one was a type 2 MI, and there were four stent thromboses, occurring in the time period after the index procedure.

We also performed an exploratory analysis excluding all the procedure-related MIs because these peri-procedural MIs might be challenging to the primary outcomes, and we observed in this analysis again that non-inferiority occurred, and again, we saw a lower rate of myocardial infarction with a hazard ratio of 0.52 and a p-value just non-significant at 0.052. In addition to that, a pre-specified analysis of clinical events at 30 days demonstrated superiority in terms of the primary outcomes for the immediate complete revascularization compared to staged complete revascularization approach.

So, we concluded that an immediate complete revascularization strategy is non-inferior to a staged complete revascularization strategy when treating patients with acute coronary syndrome and multivessel disease. Immediate complete revascularization strategy may also reduce the rate of myocardial infarction and unplanned ischemia-driven revascularization.